I'm going to step out on a limb here. I know this might be specific to specialty, facility, co-workers, etc...
What ever happened to nurse's discretion? I know there are multiple threads on autonomy, but good god.
(1) Case in point: Pt with GI bleed. Starts having frequent bowel movements of bright red clots/blood. BP remains stable but not for long. I page MD about 4 times before he responds. In the meantime her fluids are at 50cc/hr. I ensure pt is not CHF/Renal/Hypernatremic etc.. and turn fluids up to 200cc. Systolic now in mid 80s after being about 115. Pulse up etc etc... I'm literally grabbing the phone to call a RRT and the doc finally shows up and xfers her to an appropriate level of care and personally thanks me for turning fluids up etc... (other VSS btw)
The first thing I hear out of my charge nurse's mouth is that I acted inappropriately because I did not have a physician's order (to turn up fluids) and that I am receiving a warning "this time."
(2) I'm looking up the results of an abd ultrasound. There is some medical verbiage I don't understand and I look it up to clarify. When passing along the info in report. (just as an FYI) I get a response from the receiving nurse, "Oh, we don't have to worry about that, it doesn't really involve nursing."
(3) I have a pt that is in mild resp distress. Crackles to lungs. Just came up from ED. 5L NC isn't cutting it. Pt is not COPD. I run to grab mask. Charge nurse walks by and the first thing out of her mouth is: "You can't have an O2 mask on a med-surg floor, and plus, you need an order for that." (just for the record, ran to get Lasix IV shortly after once I had the all-powerful "order")
(4) Oncoming RN is ****** at me because there are three spots of blood on sheets of disoriented pt who I had to physically wrestle down and stimultaneously draw a PTT for a Heparin gtt. Noted increased PTT and had gtt titrated down before change of shift so oncoming RN would not have to deal with it.
I'm not sure if these examples truly represent what I'm trying to communicate. I just constantly see a growth in nursing as task oriented vs. brain oriented. Is there such thing as nurse's discretion anymore?
I feel as though the focus is so much on protocol and procedure as though you are acting as a robot vs. real critical thinking. Sometimes I want to scream at the top of my lungs, " Who gives a flying **** if we can't have a non-rebreather on this floor! The point is, at this time, the pt needs it for adequate oxygenation!"
Don't get me wrong, there is a time and place for procedure/protocol. But let's re-evaluate what is and what is not important. I don't profess to be an MD. I'm not going to do open heart surgery etc... without an order. However, god forbid I want to go above and beyond and learn as much as I can about my patients because it helps me see the "whole picture." God forbid I'd like to take an immediate action that I feel is necessary for the stability of my pts.
I'm bright eyed and bushy tailed. Those of you with years of experience, please tell me I'm not insane for my mode of thinking.:confused:
Specializes in Spinal Cord injuries, Emergency+EMS.
If my patient has spiked to 40 for the second time during my night shift after standing orders have been fulfilled and meds given, you bet your sweet (fill in the blank) that I am going to draw the blood cultures myself and send them down to the lab. I would rather have the cultures incubating so that we can identify the bug and treat the patient already instead of waiting for the doc to arrive from home in order to draw it themselves.
in the evil Socialist NHS, Nurses can order lab tests and we can order imaging if we are IR(ME)R trained ...
Very nice post, Wooh. I would not want to be standing in front of the family explaining that their loved one, who placed their trust in me, died because...well...I didn't have an order.
Sounds ridiculous, huh? We all know that there is a fine line regarding scope of practice. We aren't talking running roughshod over policy and procedure, but we ARE talking about using our critical thinking skills and nursing judgment in order to maintain the safety of our patients.
i'm with you and others, who'd do what needs to be done...in an absolute emergent situation.
i could hold my head high, knowing i did what i considered legitimate and ethical .
would much prefer to look at myself in the mirror, versus looking at license in hand...
Basically, if you initiate anything that might need an order you have to KNOW you are right. I've been in trouble for initiating a saline lock in a sick ER patient (the doc was going to order fluids and it undermined her authority to have a lock already in). I've also been left high and dry after the doc ordered paralysis and the patient started vomiting because doc needed time to cuss out a coworker. More important than his aspirating nonbreathing patient. But he expected us to know how to manage that airway without his guidance, and we apparently did. No gold stars or extra pay when we take over for him, by the way. Different hospitals, different managers, different docs, different standards. That's part of the problem when newbies don't know whether to call a doc at midnight. Some hospitals/docs expect you to use your brains, a few others want to be able to dictate every step. Just thinking out loud.
And if I've been nursing for 20 years why do I have to take an IV start/lab drawing/IV pump/insulin admin/TB testing etc course every time I start at a new hospital? If I'm doing it right just add it to the orientation check offs. BLS every two years for 26years? Send me a memo, and tell me about the changes officially at ACLS (every two years), or at NRP, or TNCC, ENCP, PALS, or the next staff meeting, because when half the staff is doing the new protocol and half are doing the old, well, we get a little flummoxed.
Totally off track now. My list of pet peeves for this hour.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
in the evil Socialist NHS, Nurses can order lab tests and we can order imaging if we are IR(ME)R trained ...
*** It's the same in my hospital, and the whole health system by policy. We can order nearly any lab and chest and abdominal x-rays. We can also order STAT head CTs as part of our stroke protocal. We need to be able to explain our rational for ordering labs and x-rays.
For the past few years all we have heard is "you must use critical thinking" . At least you have a charge nurse that is watching what you do. Maybe you should elicit help from the charge nurse or find out if you have a Rapid Response team in your hospital to assist in your decisions. I would have done the same as you. But not all nurses have the same knowledge about what to do when patients start to go bad. Sounds like you need to work in the ICU where these responses are encouraged and respected.
Specializes in Tele/med surg/step-down, Cardiology.
Just looked up the new policy and it said that med/surg nurses are not to administer IVP Metoprolol, instead, are to call rapid response team to administer the drug IVP for emergency/one time dose situations. This part of the policy is not new.
It did not state specifically which of our units they are considering to be med/surg, but I've been told by my friends who are cardiac PCU RNs that they we told not to administer Metoprolol IVP which they could do in the past so I think "MS rules" apply to them, now.
(disclaimer: I am a CNA so I'm not kept in the loop of such subjects... but this is what I'm told! lol)
Ok I am a little confused. IVP Metoprolol is used when a pt is NPO on my hospitals med/surg floors. I work on a cardiopulmonary med/surg floor and use it for the same reason, but have also used for A Fib or just a pt that BP is high and they want to give an extra dose. So that one time dose has to be administered by your RRT?? Our team is called an MRT and I can't imagine they would be thrilled to be called to do that? I question if there has been a problem or situation at your hospital that brought on this policy.
Yes petroleum jelly is combustable, it is also petroleum based and should never be used on lips or face especially with o2 due to combustion possiblity and also aspiration . . . .k-y jelly should be used instead for moisturization along with frequent oral care.
Yes petroleum jelly is combustable, it is also petroleum based and should never be used on lips or face especially with o2 due to combustion possiblity and also aspiration . . . .k-y jelly should be used instead for moisturization along with frequent oral care.
I hope you are joking about this (although I do agree with the frequent oral care). In the grand scheme of all the potentially dangerous things we give to pt's, I really don't think that petroleum jelly is a big deal.
:confused:
ZippyGBR, BSN, RN
1,038 Posts
in the evil Socialist NHS, Nurses can order lab tests and we can order imaging if we are IR(ME)R trained ...